Benefits

Value PPO

This plan is a High Deductible Health Plan. Use a Health Savings Account (HSA) to set aside the deductible pre-tax.

This is a summary of the plan benefits. Complete benefit information is available in the High Deductible Health Plan (HPHP) Booklet , HSA Value Plan Booklet and Summary of Benefit Coverage (SBC) .

Express Scripts - administered prescription plan
Vision discount - program available through Davis Vision
Blue Extras - offers a variety of discounts on gym memberships, alternative medicine and hearing aids

	In-Network	Out-of-Network
Group Number	006171
Deductible	$1,400 Member*; $2,800 Family	$1,400 Member*; $2,800 Family
Coinsurance	20%	40%
Out-of-Pocket (OOP) Maximum	$3,000 Member*; $8,000 Family	$6,000 Member*; $16,000 Family
Prescription OOP Maximum	Included in health OOP max	Not Applicable
Wellness Checkup	Covered 100%; procedures covered according to age/sex guidelines	Deductible + 40% Coinsurance
Office Visit	Deductible + 20% Coinsurance	Deductible + 40% Coinsurance
Emergency Room Costs	Deductible + 20% Coinsurance	Deductible + 40% Coinsurance

* Individual deductible and out-of-pocket maximums do not apply to family coverage

Covered at coinsurance after deductible is met
- Self management training services rendered by a physician or licensed health care professional with expertise in diabetes management
- Regular foot care examinations by a physician or podiatrist

Hearings aids; discounts available with TruHearing at 866-687-2020
Custodial Nursing Home Care Cosmetic Care except for the correction of congenital deformities or for conditions resulting from accidental injuries, tumors or disease

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